Facility Evaluation Report

On this day Licensing Program Analyst (LPA) Fred Arias made an unannounced visit to conduct a required annual visit. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit. Facility is licensed for 6 non-ambulatory residents. Facility has an approved hospice waiver for 6 residents and the home currently has 5 residents, with 1 resident on hospice. Staff provided liability insurance that expires on 10/19/2025.

LPA along with staff member 2 (S2) toured the facility at 8:35 AM. LPA toured the physical plant, checked food service and facility documentation. The home consists of 3 resident bedrooms, living room, dining room, kitchen, two staff rooms with one built into the garage, as well as 2 bathrooms. LPA toured the kitchen and observed sharps locked in a cabinet during today's visit. At 8:40 AM, LPA observed a kitchen cabinet with a broken lock containing medication. Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Kitchen appliances were operational during today's visit . LPA observed the emergency food. At 8:58 AM, LPA observed there is no emergency water at the facility. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure and shower was free of mold/mildew. At 9:09 AM, LPA observed unlocked bathroom cabinet with cleaners such as Comet bleach powder and Clorox wipes inside bathroom in bedroom 3. Water temperature measured between degrees 114.4 F and 114.9 in all bathrooms. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Auditory exit alarms were operational during today's visit . Smoke detectors tested operational during today's visit. Fire extinguishers were fully charged. Continued on LIC809-C dated 5/23/2025.